2.003 - How You Can Help Save the US Healthcare Systems - Direct Primary Care Lessons from Lee Gross, MD

July 04, 2023 Coach JPMD Season 2 Episode 3
2.003 - How You Can Help Save the US Healthcare Systems - Direct Primary Care Lessons from Lee Gross, MD
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2.003 - How You Can Help Save the US Healthcare Systems - Direct Primary Care Lessons from Lee Gross, MD
Jul 04, 2023 Season 2 Episode 3
Coach JPMD

Have a Happy 4th of July!!!

In this episode, Coach JPMD interviews one of America’s pioneers in Direct Primary Care and advocate for healthcare reform, Lee S. Gross, MD.  Dr. Gross describes his journey from practicing fee for service medicine to running a membership based practice where he does not accept insurance.  His knowledge and expertise has also led his organization to save a local rural hospital and believes this is one of the keys to healing our broken healthcare system. You will not want to miss this episode as they discuss his passion and gift for simplifying complex systems.

You can watch this episode on YouTube here.

Show Notes

Show Notes Transcript

Have a Happy 4th of July!!!

In this episode, Coach JPMD interviews one of America’s pioneers in Direct Primary Care and advocate for healthcare reform, Lee S. Gross, MD.  Dr. Gross describes his journey from practicing fee for service medicine to running a membership based practice where he does not accept insurance.  His knowledge and expertise has also led his organization to save a local rural hospital and believes this is one of the keys to healing our broken healthcare system. You will not want to miss this episode as they discuss his passion and gift for simplifying complex systems.

You can watch this episode on YouTube here.

Show Notes

Coach JPMD  0:04  
And I'll let you introduce yourself as well. So, you know we'll...Welcome to the practice impossible podcast. Where your host, Jude a Pierre MD, also known as Coach JPMD discusses medical practice topics that will guide you through the maze that is the business of medicine, and teach you how to increase profits and help populations live long. Your mission should you choose to accept is to listen and be transformed. Now, here's your host, Coach JPMD.

Well, welcome Dr. Lee gross. Welcome to the Practice Impossible podcast. Season two, we're actually season two, episode two. And it's all about practicing medicine, independent of corporate medicine, independent of the controls are that we are so used to. And Dr. Gross is with us from North port. I guess it's a little bit north of Fort Myers, I think. 

Lee S. Gross, MD  1:05  
Absolutely. Southwest, FL.

Coach JPMD  1:07  
Right down the road. And I 75.

Lee S. Gross, MD  1:10  

Coach JPMD  1:12  
So Dr. Gross is the founder of Epiphany, health physicians and his family physician, also a national speaker for the direct primary care is it a coalition or a direct primary care group? 

Lee S. Gross, MD  1:29  
Just the movement in general. 

Coach JPMD  1:31  
Okay. And you've also testified in the US Senate as well, which is pretty impressive. So I'll let you continue that introduction and tell us about direct primary care and what that what that is because some of our listeners don't know, and love for you to help us understand what you do. 

Lee S. Gross, MD  1:50  
Sure, absolutely. So I am a family physician by training originally from the general, the Greater Cleveland area, graduated from Case Western Reserve University and did my training at University Hospitals of Cleveland. And in 2002, decided to look at what our options were in terms of practicing and family medicine. And then the Cleveland market at the time, back in 2002, you had basically two options. You had a market that was dominated by two massive organizations, the Cleveland Clinic Foundation, and University Hospitals of Cleveland. And those organizations were essentially consuming and gobbling up the entire market of physicians and ambulatory surgery centers and everything so that they controlled everything. So basically, you either worked for one of those two organizations, or you didn't practice as a physician in the Cleveland area. And that was not something that I really was interested in. So I sort of looked outside of the Cleveland market and found southwest Florida to be a very attractive place to do practice primary care. So I joined a group in southwest Florida in 2002, as a multi specialty group, and after a couple of years, bought my practice from the group and took it solo. So in 2004, became a solo primary care physician. And, interestingly, I was just like most other primary care physicians, at the time, I was completely insurance based practice. I contracted with Medicare, Medicaid, I contracted with all the commercial carriers. And I was on a rat race for trying to figure out how to keep my practice afloat. And every time I found a way to generate more revenue for my practice to keep my my income stream coming in, the insurance companies or the federal government or Medicare would change a rule to make that an unreliable source. So, for example, we used to do stress tests, you know, as a primary care doctor, you would think that the number one cause of death in the country being heart disease, you would try to diagnose that before the heart attack. And so we were doing stress tests. Well, Medicare, basically banned the arrangement that we were doing to de stress tests. And so we started doing it another way Medicare outlawed that or changed the rules on that. And eventually, we had to sell our treadmill. We were early adopters of electronic medical records, because they made phenomenal sense for our practice. They were excellent for our workflow that made us more efficient, they automated tons of tasks that we that we were doing, until they made it mandatory. And then when they made it mandatory and required Meaningful Use. The EMR that we were using that was perfect for our practice was no longer a certified EMR. So we started accruing Medicare penalties because we weren't using a certified EMR. We were just using what worked for our practice. So we converted over to the certified EMR that was compliant, but the compliant EMR didn't do anything. We needed it to do that just stop the penalties. And now we had to run parallel systems, one that did the job and one that kept us from getting penalties. And we were on this hamster wheel of playing Whack a Mole with the carriers and with the with the government and the insurers that we just said you know what, we weren't happy, our patients weren't happy, we were having to funnel tons of people through the office trying to find a multitude of things to do to them to generate revenue, because the level three visit needed to become a level four visit and a level four visit needed to become a level five visit and, and it was exhausting. And I was unhappy and the patients weren't happy. So the name of my practice now, this is a long winded introduction, but it's relevant, especially to the people that that have not been through what we have been through in private practice 20 years ago. The name of my practice is epiphany health right now. And that's a really strange name for a practice. But we had an epiphany and the epiphany was in that background to say, why are we ensuring primary care? Why are we inserting so many obstacles and barriers between doctors and patients, and then filing a claim for every single basic interaction between doctor and patient, and then we're upset because it's expensive, it's impersonal, it's cumbersome, we get surprised bills in the mail. And so our epiphany moment came when a small business owner came up to us and said, Doc, my insurance premiums, for my employees are skyrocketing. And they all see you as their primary care doctor, I know what I paid the insurance companies, and I see what they pay you. And I'll tell you what, we're getting screwed. He said, Why don't I just hire you directly to take care of my employees. And then I'll take out a major medical plan against them for major catastrophes. And that was our epiphany moment is, you know, we don't need to ensure this we can work directly with with our patients and with small businesses. And so we created a business model in 2009. That was a subscription based model kind of like Netflix's today where we charge a flat monthly fee for unlimited medical care. And it turns out that that was one of the earliest direct primary care practices in the country. So anything that we can do on our office was included in that membership fee. So no co pays no deductibles, we don't build any any third parties. So I'm sorry to keep on going. But I promise I will give you a word in here. 

Coach JPMD  7:05  
No, no, this is great. This is great. 

Lee S. Gross, MD  7:07  
So So in 2010, on in January 1 2010, we flip the switch and turn down this crazy idea. And the interesting thing happened is that we started seeing uninsured patients come to our practice in southwest Florida from all over Florida. We started seeing patients from Miami patients from Orlando patients from Naples, and they would drive two or three hours away, because they could afford what we were charging. At the time, we were charging $89 a month for an adult. And we were charging about $49 a month for a child for unlimited care. And by the way, fast forward to 2023. So 13 years later, my price for an adult is now at $85 a month. So the skyrocketing cost of health care has caused us to keep our prices flat now for 13 years, and the children are as low as $15 a month now, again, skyrocketing cost of health care. So the cost of coverage has massively exploded at 15% per year, our prices have been flat for over a decade. But it created an interesting problem for us because now we had a massive uninsured population that we now had to find ways to provide affordable care for them outside of our office because you know, we're just primary care. But we need labs, we need imaging, we need physical therapy. And now we need some maybe specialty care. So we created an entire cash based network of independent laboratories independent imaging centers. And it turns out that when we did this, the prices for cash were cheaper than most patients co pays when they had insurance. And so our cash price for bloodwork for everything was $45. And we were seeing 95% discounts offered to you know $2,000 For the bloodwork we can get for $80. Our cat scans are $175. Our MRIs are $225. Our X rays are $30. And so what are we ensuring when using the insurance actually blocks people's access and drives up the cost out of pocket for the services. So here we are 13 years later, still alive and flow. We have four physicians in two locations. We started up a nonprofit foundation and Docs for Patient Care Foundation. And through the work of our foundation and advocacy, federal and state advocacy. We've helped nearly 2000 physicians across the country, startup DPC practices through our training programs.

You You said so much and I can go in so many different directions here. But so are you would you be considered a concierge practice? Or what's the difference between concierge and direct primary care before we even get into the details of what you said because there's so much in there. 

Yeah, so I think there's a lot of overlap in in the terminology. Some of its intentional. I would say the concierge is sort of where the direct primary care model probably initiated it started. So the analogy I like to use is that airbags when they first came out, they were only on high end luxury automobiles. But now they're standard on every single entry level car. And so when concierge came out, it was sort of elitist. It was, you know, high price for the wealthy, you know, the worried well, with concierge level, executive physicals and sort of things. And now, it's being done at a price point where if you can afford a cell phone, you can afford a direct primary care doctor.

Coach JPMD  10:33  
 Yeah. And that model that you're describing is less than one would pay... I mean, I look at the statistics, I pulled up this statistic. Actually, I want to share this with the audience and kind of... I'm sure you've seen this. Can you see my screen? 

Lee S. Gross, MD  10:56  

Coach JPMD  10:57  
So this is the annual expenditure of all consumer units in the United States in 2021. By statistics, statistics, and healthcare expenditure is about $450 a month, that, that the consumer pays for health care in this country. You're saying your model is much less than that. It's it's $85 a month, but it includes these other ancillary services. And I'll include that in the show notes. By the way..

Lee S. Gross, MD  11:27  
It includes access to the to the negotiated cash prices that we have. So we have transparent cash prices, we don't bundle in MRIs and CAT scans and those sorts of things. But we do have nine different imaging centers in three counties that I worked with that provide cash prices. Now we have cash price surgeries, we have a cach based hospital that we're working with. And so if you have no insurance, then the prices for these things are affordable for most people's budgets for services, things that people think are, they had to have insurance for, are actually more affordable for most people. And, in fact, a lot of times people are paying so much for their insurance, and their deductibles are so high that they actually can't afford their insurance and the services they need. So they ended up picking just the insurance and skipping their health care. 

Coach JPMD  12:20  
Yeah, that's very interesting. So So is this similar to the Christian Health Network, I've heard this advertised online or in radio stations, where they're, they're creating a membership model for a group of people? Would that be something similar that to what you're doing? 

Lee S. Gross, MD  12:38  
So I think what you're referring to are the health sharing ministries, which there are many varieties of, and those pair up very nicely with what we're doing. So the way I can remember that where I, you know, when I grew up was I grew up in northeastern Ohio, so we had a very large, Amish community that that they had no health, they don't use health insurance for their medical care. And so one of the members of their community gets sick, they pass around a hat, they go from home to home and collect money to pay medical bills. So the sharing ministries are same general concept where, whether it's faith based, and oftentimes it is faith based, where they pull together their resources to pay each other's medical bills. And now that insurance is getting so expensive, this concept of pooling money to cover each other's healthcare costs is becoming more and more popular in the health sharing world. But those are again, uninsured patients sharing costs. So they are all cash based consumers trying to shop in a store, which is our crazy healthcare system that has no prices on it. So we go through that store, we put prices on everything. So we provide the primary care services and free cash based services. And we've gone well beyond that now in our contracting with self insured employers and self funded health plans and so forth. 

Coach JPMD  13:57  
So So going back to the original model of that employer that came to you that had one of their members or their employees to come to a to you for care. He said that they purchased a catastrophic plan. So you have you have this group of patients who you know, get regular primary care and they do their their bloodwork, their cholesterol or diabetes screening, but then they get cancer, that catastrophic plan would cover the cancer treatment, or how would that how would your model help in treating patients who are going for cancer treatment where medicines are costing $10,000 a month, $20,000 a month? 

Lee S. Gross, MD  14:35  
I think pretty much every model of care is always complicated when you're dealing with high cost long term issues. I think most of them handle like a one time major cancer event fairly well. It's that sort of ongoing, you know, chronic condition that's high cost that may last you know 10-20 years. But so yes, I'm you know a high cost catastrophic insurance, you know, may have a $10,000 deductible. But once you hit that 100% of your costs are covered by the insurance plan. And so yeah, that's, that's very helpful if you needed, you had a heart attack, you needed a bypass surgery, your out of pocket costs are capped, and $10,000. Sounds like a lot of money. But honestly, on the Affordable Care Act exchange, the average deductible nowadays is about 10 to $12,000.

So, you know, at the time 10 to $12,000 seem ridiculous, but now of that's actually the norm. Every plan out there is a high deductible plan, and every patient now is essentially a cash paying consumer. 

Yeah, and I'm one of those patients, right? Because I have a high deductible plan, am I I think my deductible is between five and $10,000, depending on the price of the procedure. And what I did, for my wife, actually, my wife actually found a functional medicine doctor who took her off her her medicines, took her off her thyroid medicines, and, you know, did some specific bloodwork that aided her and guiding her through supplements and physical like physical things, physical activity, things that that has helped, but it costs us a lot of money on top of what we're already paying for insurance. So what you're saying is, those consumers would not have insurance by their employers at all, or how do they get a cast catastrophic plan? Its employee..

Coach JPMD  16:25  
So it's tricky. 

Lee S. Gross, MD  16:27  
Now, I will tell you that when we started this, it was very easy, because those plans were widely available, just plans would cost $50 a month, the Affordable Care Act, outlawed those plans they're illegal to buy now. And so you can't buy unless you're under the age of 35. You can't buy a catastrophic only plan that's compliant, that nobody really sells them. They're trying to make a comeback. But that, again, is just a fight over, you know that you can't have junk insurance policies because they need to cover everything. Well, turns out when you cover everything, the policies get extremely expensive, and most people can't afford them. So some sort of subsidy. So interestingly, to your point about you and your wife and the functional and the functional medicine and coming off of medications, when I'm an insurance based doc and I have got to see 40 patients a day to pay the bills, then I have seven minute office visits, and five of those seven minutes have to be spent clicking the boxes to make sure our Meet the metrics to get paid by the insurance company. So five of those minutes, my face is in a computer with my back to the patient. And I got two minutes basically now to manage your diabetes. So either I'm going to refer you out to somebody or I'm going to write you a prescription is what I'm going to do. But it takes time to get somebody off medications. So it takes about two or three minutes to write a prescription. But it takes 30 minutes to not write a prescription. And so that's the beauty of what we do in the direct primary care model. And again, similar to the concierge model, we have the time because we're not fighting your insurance company. My staff is not behind the scenes fighting with your insurance company for authorizations and approvals. We hire clinical staff to do clinical tasks not insurance based and billers and coders. We don't have billers and coders in our, in our practice, we have nurses and medical assistants doing patient care. So I have 30 minute office visit. So I can explain to you what you need to do to come off of your diabetes medicines. And so I can write you a $600 insulin pen. Or I can spend a half an hour teaching you the lifestyle choices, and then see you back at frequent intervals or hop on a video chat to reinforce what we've talked about to get you off your meds and keep you off your meds. And that's how the system ends up saving money. 

Coach JPMD  18:40  
You're absolutely right. I saw a patient yesterday actually, she, she came in and she's trying to lose weight she has she's struggling with it. And I hadn't seen her in probably eight months. And we spent a good 10-15 minutes talking about what she needed to do. And her husband is kind of, you know, echoing what I'm saying. And at the end of the visit, she says doc, can I see you sooner than six months? Because I felt like she knew that if we had more frequent visits, we'd be able to further solidify the things that we talked about in the visit. And I said, Yeah, I would love to do that. Because it's easier for me to prescribe a medication, really, I could have prescribed ozempic or all these other medicines that, you know, they're looking to prescribe to lose weight. But once you stop the medicine, if you're not changing the mindset, then they're going to gain the weight again and go back to square zero, or it's very interesting that you're saying that like that. So how do you so you have a direct primary care model, they have a membership fee that members pay? Do you have a specific number of patients that you need to treat to cover the overhead expenses? Because I would imagine that you have clinical staff not you know, coding staff, you got to pay, you know, facility fees and what are your overhead costs and how do you how do you know how much how many patients to have the need in the membership model to cover your expenses? 

Lee S. Gross, MD  20:03  
I think you probably in your introduction to the question and answer, answer. The question is, it really depends on what your overhead costs are, and how much money you need to take home at the end of the day, which is how your fee structure is going to have to work and how many patients you need to make that happen and what your community can bear. So what works in Manhattan may not work in Arcadia, Florida, you know, different price points, different populations, different needs. You know, so what I would say is that a typical overhead cost in a primary care practice, because primary care is very overhead, intense, it's a lot of human labor, a lot of touches. And it's very heavily Office, Office base. So typical primary care runs 50 to 60%. Overhead, and an independent practice, the direct primary care practices run closer to 30%. Overhead, some of them run a little leaner than that, some run a little heavier than that, but it's but 30 is probably about the national average, from what I've seen, most practices run between 600-700 patients for a full load. With that, you know, typical primary care doctor can make as much as a, as a primary care doc in the system on that on the treadmill.

Coach JPMD  21:22  
Yeah, running from place to place and doing the things that we continue to do and not be informed of these things. And these practices.

Lee S. Gross, MD  21:33  
And it's not headache free. I mean, you know, it's still challenging, it's still complicated. This isn't Country Club medicine, we're not treating the worried well, in fact, what we attract are some of the sick of the sickest of the sick patients that need the extra time. And so oftentimes, we get accused of sort of cherry picking the Healthy People and leaving a sick for the system to take care of. And in fact, it's usually the opposite. It's the sick that have heavy needs, that the system sort of highlights the failures of our broken system that for causes them to seek out Doc's like us that have the time and the ability to provide the intense. 

Coach JPMD  22:11  
Yeah, and are they are they? I don't want to say willing to pay, but yeah, say are they willing to pay? So those those sicker patients, they have multiple medical problems? Some of them have psychosocial problems, poor living situations? Are they seeing the value in paying that $85 a month?

Lee S. Gross, MD  22:30  
Yeah. And if they don't, they don't renew the membership. I mean, that's, that's the beauty of sort of market forces is that, you know, if we're not providing a valuable service to them, and they don't perceive the value, then they won't come back. They won't renew it. I mean, they have the option to cancel if they if they choose to. Our retention rate is fairly high.

Coach JPMD  22:52  
And for those that are leaving, do they do you find that they're at risk for the practice, if they're leaving the practice, and they're not paying the membership fee anymore? And they perceive it as not something that is valuable to them? How do you see that as a risk to your practice? 

Lee S. Gross, MD  23:05  
Yeah, I think we have a sort of a constant churn level of new patients to the patients, leaving out of our practice, it's probably about 1% per per month that, that cancel memberships. You know, the most common thing I might hear is, you know, I have new insurance now, and I'm gonna go find a doctor that takes my insurance. And quite honestly, they come back, you know, they experienced what it's like to have, you know, wait two months for an appointment. And oh, by the way, when you're sick, you can see me in three weeks, you can see my nurse practitioner next week, or you can go to the emergency room, urgent care now. And, you know, they don't get messages returned. And so that's sort of our best marketing is to have people sort of go out and experience what, what it's like in some of these, you know, large corporate practices that are all about, you know, filing as many patients through as possible, waiting two hours to be seen in the waiting room, and then getting two minutes with the doctor. That gets frustrating quick, so those patients do end up coming back. So that's actually good marketing, marketing for us. I'd love to talk a little bit about some of the work that we're doing in rural health care, too, because this is something that doesn't just work in, in, in North port Florida, which by the way, is one of the fastest growing cities in the state of Florida, if not in the country. But we also have an arrangement in Arcadia, Florida, it's DeSoto County, second poorest county in the state of Florida. And we have a relationship with DeSoto Memorial Hospital. It's a 49 bed, rural hospital. And if you're following the plight of rural hospitals across the country, they're they're desperately seeking life support. And COVID was was miserable to them. And so we've probably in the last three years lost over 100 rural hospitals and once they go they don't come back. So we partnered with a rural hospital, and if any of their employees sign up with our direct primary care practice, the hospital pays for their membership for them. And then they restructured their employee health plan around our practice, and said, Okay, if any of these employees that are seeing Doctor gross in his practice, have any services done, they're 100%, automatically covered, and we'll waive all copays and all deductibles. So they've given us free rein and eliminated all step at its prior authorizations and anything whatsoever, as long as it's done in the hospital. And so any service that's done through us is free to the employee, and paid for by by the hospital. And we're now four and a half years into that arrangement we've saved by eliminating deductibles eliminating co pays, providing access to free primary care with no co pays no deductibles, we've saved that hospitals employee health plan 55% of the employee's premiums have been reduced 30%. And they have not increased one penny in almost five years. And so this hospital while most hospitals are sucking wind has has had some of its best financial years in its history, because we've taken their number two line item expense behind human labor, which is their employee health plan costs and reduced it by 55%. And frozen it for five years. That is something that is unheard of if that were done in a Medicare population, that would be front page of The New York Times above the fold.bAnd yet we're doing it in one of the most vulnerable populations and providing better care and better access.

Coach JPMD  26:30  
So So why why wouldn't at least the Florida government Look at that? Why wouldn't... They are.

Lee S. Gross, MD  26:37  
They are. Everybody's looking at it. We're yet we're we're speaking with the governor, governments from Utah and Montana and Texas and Wyoming. And, yes, people are definitely paying attention to what we're doing in Central Florida. 

Coach JPMD  26:54  
Well, I think that's, that's, that's amazing, because I think it gives hope to those physicians that are coming out, that may not understand what you just said, and maybe you should go back and listen, and research this. And maybe I'll if you have any articles, I'd love to post some articles about these numbers that you're showing. Because if we if we can slowly tell physicians show physicians that this model is possible, and then go and take it to other rural communities, because I live in somewhat of a rural community in this area. And the hospital costs are insane. You know, CAT scans of the abdomen, chest costing $18,000, even though they have insurance and their Medicare Advantage insurance, and so they're fleecing the Medicare system, just because they have insurance, because they went as an outpatient versus an inpatient because they didn't go to an independent Diagnostic Center. So it's just, it's just a mess. But if you're saying that you have a model that that works like this, and hospitals can make more money, I'm not sure why they wouldn't do it. 

Lee S. Gross, MD  27:54  
So in 2019, the rural accountable care organizations are really co saved $63 per beneficiary, and then our first year we saved them $2,000 per beneficiary. So it's not even a fair fight in terms of sort of practice, design and structure. The other thing that we did with this hospitals, we created cash based surgical bundles for uninsured patients. So we created a draw for medical tourism into this rural hospital. So while most rural hospitals see patients leaving the community for care, we've created a demand for community or for services to come into this community for elective colonoscopies, elective hip replacements, elective knee replacements. And so because of the quality and drive that we've done, we've turned a hospital that basically didn't have enough volume, even have a single CMS star. It's now one of the few five CMS star hospitals in the state of Florida. 

Coach JPMD  28:49  
That's amazing. It's amazing and needs to be it needs to be broadcast all over. So I hope that, that's you're practicing impossible. That is exactly what we do here. So I know that you're you've got a hard stop coming. And I'd love to continue the conversation. But there's so many questions I have and I'm sure my audience have similar questions. And if they want to get a hold of you, as hear, hear what you have to say how what's the best way to to contact you. 

Lee S. Gross, MD  29:23  
So they can go to my practice website. It's, and that's where you can read about our practice and the practice model and the structure. We also have a nonprofit foundations called Doc's for Patient Care Foundation. That's And every year we put on direct primary care conferences grant supported where we teach physicians how to structure their practices and give them details on how to make this successful for themselves. Bring physicians from around the country so we typically have two or 300 Doctors attend these conferences. We're expecting to put this one on this year in Dallas probably in November. And so if you go to our Foundation website, sign up for newsletters and you will get some information about when our next conference.

Coach JPMD  30:19  
Excellent. So, you know, before we leave, I'd like to do something that I've done a couple couple of times before and that's some rapid fire questions. I didn't really ask about family and you know, I see I see someone in the background I'm not sure if that's you or your your son.

Lee S. Gross, MD  30:37  
That's an old picture of my one and only son, who is 22 years old just graduated from Florida State University with a 4.0 GPA, and is now off to Nashville to get his master's degree at Vanderbilt School of Business. 

Coach JPMD  30:51  
Very nice. So he'll be he'll be running things soon, eh?

Lee S. Gross, MD  30:57  
I hope so.

Coach JPMD  31:00  
So, so let's go through the rapid fire. one word answers or one phrase answer. Favorite color. 

Lee S. Gross, MD  31:07  

Coach JPMD  31:10  
My too. Favorite movie. 

Lee S. Gross, MD  31:13  
Oh, Hoosiers. 

Coach JPMD  31:17  
Last book you read

The last book I read A Dog's Purpose.

I'm gonna list all these things. I have to research this stuff to one thing your wife really likes about you. 

Lee S. Gross, MD  31:31  
Probably my sense of humor. Maybe my cooking would be probably a number two. 

Coach JPMD  31:35  
Okay. favorite vacation spot? 

Lee S. Gross, MD  31:38  
Right now it's Costa Rica boy thats beautiful, put it on your list if you havent' been.

Coach JPMD  31:43  
It is on my list and I haven't been Yeah. Favorite child, I guess you know that.

Lee S. Gross, MD  31:48  
Wow, that's a tough one. You don't hold any punches.

Coach JPMD  31:55  
What time do you wake up?

Lee S. Gross, MD  31:58  
At six o'clock in the morning.

Coach JPMD  32:00  
Dream Car.

Lee S. Gross, MD  32:03  
That doesn't really matter to me.

Coach JPMD  32:07  
I like that answer. One thing your team does not know about you.

Lee S. Gross, MD  32:12  
One thing my team does not know about me. Ah, well, I'm kind of an open book. Not sure a lot of people know that I spent three years as the research coordinator for the Cleveland Clinic for their cardiology program before I went to med school because it took me four years to get into med school. And I applied and got rejected, applied and got rejected, applied and got rejected. And so I took a job as a as a this is not a one word answer took a job as a file clerk for the Cleveland clinic's cardiology program. And in six months, worked my way up to the research coordinator of the cardiology Research Program, which sort of launched my, my medical school prospects. And so I worked for Eric Topol, who's now the, the director of Medscape he was the chairman of the department at the time. And he basically is the guy that wrote me my letter for medical school and got me got me accepted the Case Western Reserve, so I appreciate his help immensely. 

Coach JPMD  33:15  
That's an awesome story. And it doesn't sound like you're gonna have a pet peeve. What's one...

Lee S. Gross, MD  33:25  
I don't like running late. My, my staff will tell you if there's one thing that gets me in a bad mood, it's to get me behind schedule. When I when my schedule is says that your appointment time is at 10 o'clock. That means my hand is on your doorknob at 10 o'clock, not 10:07. And so I like to run on time, which means I'd like my patients to show up on time. So timeliness.

Coach JPMD  33:52  
Dr. Gross. Thank you. Thank you so much for such an educational inspiring story. I'm sure our audience is going to enjoy this and thank you again for for coming on the practice possible I guess. 

Appreciate you having me. Thanks.

Alright, Dr. Gross. Thank you.